Sinking bone flap due to overdrainage of a ventriculoperitoneal shunt. A case report and review of the literature / Hundimiento de colgajo óseo por sobredrenaje de una derivación ventriculoperitoneal. Caso clínico y revisión de la literatura

The widespread use of decompressive craniectomy and subsequent cranioplasty has led to a better understanding of its complications. However, cases of a sunken bone flap have hardly ever been described. We present the eighth case reported up to date and perform a review of the literature of this sporadic complication. A 40-year-old Caucasian male suffered a traumatic brain injury that required a decompressive craniectomy. One month after initial trauma autologous cranioplasty was performed. A ventriculoperitoneal shunt was also placed. Neurological status progressively improved but his therapist noted cognitive status decline 8 months later. Follow-up computed tomography showed a progressive sinking bone flap. The patient underwent bone flap removal and a custom-made calcium phosphate-based implant was inserted, leading to symptoms resolution. Bone resorption has been described as the main cause of sinking bone flap following cranioplasty. This entity may manifest with symptoms of overdrainage in patients with cerebrospinal fluid shunt devices (AU)

El uso extendido de la craniectomía descompresiva y la consiguiente craneoplastia ha propiciado un mejor conocimiento de sus complicaciones. Sin embargo, esporádicamente se han descrito casos de hundimiento del colgajo óseo. Describimos el octavo caso descrito hasta la fecha y realizamos una revisión de la literatura de esta infrecuente complicación. Un varón de 40 años sufrió un traumatismo craneoencefálico que requirió craniectomía descompresiva. Un mes después se sometió a la reposición de su colgajo óseo, junto con la implantación de una derivación ventriculoperitoneal. Presentó mejoría neurológica progresiva que se frenó y empeoró ocho meses después. La tomografía computarizada de control mostró hundimiento progresivo del colgajo óseo. El paciente se sometió a la retirada del colgajo óseo y cranioplastia con implante a medida, con resolución de los síntomas. La resorción ósea se ha descrito como la principal causa del hundimiento del colgajo óseo tras cranioplastia. Sin embargo, esta entidad puede manifestarse como síntomas de sobredrenaje en pacientes con derivación de líquido cefalorraquídeo (AU)

Long-term quality of life after decompressive craniectomy.

Introduction: This study aims to assess the quality of life (QoL) in patients who have undergone decompressive craniectomy (DC) for any pathology that has caused life-threatening intracranial hypertension. Similarly, it aims to evaluate QoL perceived by caregivers or external informants. In addition to that, the last purpose is to determine which clinical or therapeutic factors could correlate with a better QoL. Methods: A single-center cross-sectional study was designed. All patients over 18 years old who underwent a supratentorial DC at our department due to intracranial hypertension of any etiology, from January 2015 to December 2021, were retrospectively selected. Patients with incomplete follow-up (under 1 year from the event or those who died) or who declined to participate in the study were excluded. QoL was assessed with SF-36 and CAVIDACE scales. The correlation between clinical and therapeutic variables and SF-36 subscales was studied with Spearman's correlation and the Mann-Whitney U-test. Results: A total of 55 consecutive patients were recruited: 22 patients had died, three were missed for follow-up, and 15 declined to participate, thus 15 subjects were finally included. The mean follow-up was 47 months (IQR 21.5-67.5). A significant reduction in the "role physical" and "role emotional" subscales of SF-36 was observed compared with the general population. According to caregivers, a significant reduction was assigned to the "physical wellbeing" and "rights" domains. The "physical functioning" score was poorer in women, older patients, those with dominant hemisphere disease, those who required tracheostomy, and those with poor outcomes in the modified Rankin scale. A strong correlation was found between the QoL index at the CAVIDACE scale and the SF-36 subscales "physical functioning" and "role physical". Conclusion: Most patients and caregivers reported acceptable QoL after DC due to a life-threatening disease. A significant reduction in SF- 36 subscales scores "role limitation due to physical problems" and "role limitation due to emotional problems" was referred by patients. According to caregivers' QoL perception, only 25% of the survey's participants showed low scores in the QoL index of the CAVIDACE scale. Only 26.7% of the patients showed mood disorders.

Survival following vertebral compression fractures in population over 65 years old.

BACKGROUND: Lower mortality has been demonstrated when vertebral compression fractures (VCFs) are treated surgically (vertebral augmentation) vs. conservatively. AIMS: To analyze the overall survival in patients over 65 who suffer a VCF, to review the principal causes of death, and to detect which factors are associated with a greater risk of mortality. METHODS: Patients over 65 years old diagnosed with acute, non-pathologic thoracic or lumbar VCF, treated consecutively from January 2017 to December 2020, were retrospectively selected. Those patients with follow-ups under 2 years or who required arthrodesis were excluded. Overall survival was estimated by the Kaplan-Meier method. Differences in survival were tested through the log-rank test. Multivariable Cox regression was used to assess the association of covariates and time to death. RESULTS: A total of 492 cases were included. Overall mortality was 36.2%. Survival rate at 1-, 12-, 24-, 48-, and 60-month follow-up was 97.4%, 86.6%, 78.0%, 64.4%, and 59.4%, respectively. Infection was the leading cause of death. The independent factors associated with a higher mortality risk were age, male, oncologic history, non-traumatic mechanism, and comorbidity during hospitalization. No statistical difference was found when comparing the two survival curves by treatment (vertebral augmentation vs. conservative) over time. CONCLUSION: Overall mortality rate was 36.2% after a median follow-up of 50.5 months (95% CI 48.2; 54.2). Age, male sex, history of oncological disease, non-traumatic mechanism of the fracture, and any comorbidity during hospitalization were identified as variables independently associated with a higher risk of mortality following a VCF in the elderly.

Sinking bone flap due to overdrainage of a ventriculoperitoneal shunt. A case report and review of the literature.

The widespread use of decompressive craniectomy and subsequent cranioplasty has led to a better understanding of its complications. However, cases of a sunken bone flap have hardly ever been described. We present the eighth case reported up to date and perform a review of the literature of this sporadic complication. A 40-year-old Caucasian male suffered a traumatic brain injury that required a decompressive craniectomy. One month after initial trauma autologous cranioplasty was performed. A ventriculoperitoneal shunt was also placed. Neurological status progressively improved but his therapist noted cognitive status decline 8 months later. Follow-up computed tomography showed a progressive sinking bone flap. The patient underwent bone flap removal and a custom-made calcium phosphate-based implant was inserted, leading to symptoms resolution. Bone resorption has been described as the main cause of sinking bone flap following cranioplasty. This entity may manifest with symptoms of overdrainage in patients with cerebrospinal fluid shunt devices.

Oral extrusion of a vertebral body replacement device after chordoma tumor growth and radiation: case report and review.

BACKGROUND: Screw migration following anterior cervical discectomy and fusion is a very rare complication and it is often related to device failure. Even more exceptional is the extrusion of an intervertebral graft. CASE PRESENTATION: We report the second case of migration and extrusion through the oral cavity of a cervical vertebral body replacement device (expandable cylinder) in a patient that had undergone cervical corpectomy due to a vertebral chordoma. CONCLUSION: The antecedent of radiation therapy as well as progressive tumor re-growth may have favored the development of this complication. A literature review is added.

Volumetric Study of Nonfunctioning Pituitary Adenomas: Predictors of Gross Total Resection.

OBJECTIVE: Despite the efforts made to determine the achieved resection grade after pituitary adenoma surgery, there is a high level of disagreement among all the available classifications and measurement methods used. Our objective is to identify the factors that preoperatively could predict a gross total resection (GTR) of a clinically nonfunctioning pituitary adenoma through an endoscopic endonasal approach. METHODS: Across 100 surgeries, we analyzed epidemiologic and clinical data, radiologic relevant data, extent of resection (EOR), and postoperative outcomes. The EOR was measured objectively through an accurate volumetric analysis. RESULTS: The median presurgical volume was 8.58 cm3 (range, 0.5-58 cm3), the median maximum diameter was 27.3 mm (range, 7-67 mm), and the Knosp grade was 0 in 1 patient, 1 in 23%, 2 in 31%, 3 in 23% and 4 in 22% of patients. In the multivariate logistic regression analysis, we found 3 factors that significantly predicted the chances of a successful GTR: previous sellar surgery, Knosp grade, and tumor signal in the T2-weighted magnetic resonance imaging scan. Another 10 radiologic variables were analyzed and had no effect on the EOR. CONCLUSIONS: Knosp grade (P < 0.001; odds ratio [OR], 25.65; 95% confidence interval, 7.19-91.52) is the most predictive factor for performing a GTR of nonfunctioning pituitary adenoma. Previous pituitary surgery (P = 0.023; OR, 5.81) and an isointense T2-weighted signal (P = 0.034; OR, 3.75) also negatively influenced the chances of GTR. We highlight the influence of T2-weighted signal in the chances of GTR.

Experimental rat model of chronic cerebral hypoperfusion-reperfusion mimicking normal perfusion pressure breakthrough phenomenon / Modelo experimental en rata de hipoperfusión cerebral crónica - reperfusión remedando el síndrome de restablecimiento de la presión de perfusión cerebral normal

BACKGROUND: Normal perfusion pressure breakthrough (NPPB) phenomenon is a major life-threatening complication that restricts the treatment of complex intracranial arteriovenous malformations. The aim of the study it to develop a rat model mimicking NPPB phenomenon that enables the evaluation of any therapy to prevent such complication. METHODS: Twenty Wistar male rats were randomly assigned to either a study or a control group. Study animals underwent an end-to-side left external jugular vein-common carotid artery anastomosis and ligation of bilateral external carotid arteries. Control animals only underwent ligation of bilateral external carotid arteries. All animals were sacrificed sixty days after the procedure. Hemodynamic parameters [mean arterial pressure (MAP), intracranial pressure (ICP) and cerebral perfusion pressure (CPP)], blood-brain barrier (BBB) permeability (measured by fluorescein staining) and histological features were then compared between both groups. RESULTS: A significant decrease in MAP and CPP was confirmed in the study group. An increase in ICP was also observed. A significant decrease in MAP and CPP was also present in the study group when comparing preoperative values with those recorded on days 0 (postoperative), 7 and 60. Fluorescein staining findings were consistent with signs of BBB disruption in study animals. Histological analysis demonstrated an increased number of pyknotic neurons in the ipsilateral hemisphere of rat brains included in the study group. CONCLUSION: These results confirm that this model mimics a vascular steal state with chronic cerebral hypoperfusion comparable to patients with AVMs behavior and disruption of the BBB after fistula closure comparable to NPPB phenomenon disorders

INTRODUCCIÓN: El síndrome de restablecimiento de la presión de perfusión cerebral (PPC) normal es una complicación grave, que supone un riesgo vital y limita el tratamiento de malformaciones arteriovenosas complejas. El objetivo de este estudio es desarrollar un modelo animal remedando dicho síndrome que permita evaluar terapias para su prevención. MÉTODOS: Veinte ratas macho Wistar fueron asignadas aleatoriamente a un grupo estudio o control. Los animales de estudio se sometieron a una anastomosis término-lateral entre la vena yugular externa y la arteria carótida común izquierdas y ligadura bilateral de las arterias carótidas externas. Los animales control se sometieron a la ligadura bilateral de las arterias carótidas externas. Todos los animales se sacrificaron 60 días después. Se compararon parámetros hemodinámicos (presión arterial media [PAM], presión intracraneal [PIC] y PPC), permeabilidad de la barrera hemato-encefálica (BHE) y características histológicas entre ambos grupos. RESULTADOS: El grupo estudio mostró un descenso significativo de la PAM y la PPC, así como un aumento de la PIC respecto al grupo control. Al comparar los valores preoperatorios con aquéllos registrados los días 0 (postoperatorio), 7 y 60 en el grupo estudio, también se confirmó un descenso significativo de la PAM y la PPC. La disrupción de la BHE fue constatada únicamente en el grupo estudio mediante la extravasación de fluoresceína sódica. El análisis histológico demostró mayor número de neuronas picnóticas en el hemisferio ipsilateral a la anastomosis de los animales estudio. CONCLUSIÓN: Los resultados descritos apuntan a un modelo que remeda el estado de robo vascular con hipoperfusión cerebral crónica comparable al que sufren los pacientes con malformaciones arteriovenosas, así como la disrupción de la BHE tras el cierre de la anastomosis, comparable al acontecido en el síndrome de restablecimiento de la PPC normal tras la exclusión de la malformación